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PubMed2004

Cases of surgery in high-responder haemophilia patients.

We present 11 cases of surgery in haemophilia patients with inhibitors (high responders). They were: one haemorroidectomy, one vesical surgery in a high responder, one adenoidectomy, seven orthopaedic procedures (one bone fixation of a femoral neck fracture, four total knee arthroplasties, two total knee arthroplasties), and one retroperitoneal haematoma that required emergency surgery. We conclude that surgery in haemophilia patients with inhibitor can be considered feasible but nevertheless remains difficult. When applied to high-responding patients the treatment must take into account both the haemorrhagic risk and the risk of anamnestic response. Use of activated fractions as first-line therapy makes it possible (if the titre of the antibody allows it) to resort to conventional replacement therapy with FVIII or FIX concentrates. NovoSeven or FEIBA can be equally used as first-line therapy including therapy for major surgeries. It can be useful to alternate one with the other in case of occurrence of haemorrhagic complications.

Adenoidectomy↗
PubMed1991

Arterial desaturation in healthy children during and after minor surgery.

Pulse oximetry (PO) was applied to 79 otherwise healthy children during and after minor ENT surgery under general anaesthesia in private practice. The PO data were not available to the anaesthetist unless desaturation to less than or equal to 85% was present for greater than or equal to 30 s. This occurred in 12 and 9 cases during anaesthesia and recovery, respectively, only 8 and 5 cases, respectively, being diagnosed clinically. Desaturation during and after anaesthesia was more common in children undergoing adenoidectomy than during procedures for which endotracheal intubation was not performed. During recovery, desaturation was more likely to occur in the same patients again. Lower values of SaO2 were found in younger children and in children resisting or crying at induction. There was a (weak) negative correlation between SaO2 and HR. As clinically undiagnosed desaturation occurs even in healthy children undergoing minor surgical procedures, a more widespread use of PO during and after anaesthesia may be advisable.

Adenoidectomy↗
PubMed2004

Convulsions on anaesthetic induction with sevoflurane in young children.

Increased worldwide use for paediatric anaesthesia of the volatile anaesthetic agent sevoflurane has mainly resulted from its low blood-gas partition coefficient and low airway irritability, providing smooth conditions for rapid induction of anaesthesia. Nevertheless, there are several clinical and experimental reports suggesting a correlation between exposure to sevoflurane and generalized clonic or tonic seizure activity. We report two clinical episodes of convulsions associated with the induction of sevoflurane anaesthesia in young children. CASE 1: during induction of anaesthesia with sevoflurane by facemask in a 3-year-old healthy boy, there were symmetrical clonic seizure-like movements of the upper extremities for 60 s. CASE 2: on re-induction of anaesthesia with sevoflurane because of profuse bleeding following nasal adenoidectomy in a 4-year-old healthy girl with a family history of epilepsy, there were symmetrical tonic and clonic seizure-like movements for 30-40 s in the upper and lower extremities. Both episodes ceased spontaneously. Although no EEG was recorded, it cannot be excluded that both episodes resulted from seizure activity within the CNS. Based on our observations and reports by others we suggest that, until further notice, sevoflurane should be avoided or at least used cautiously in patients where clinical epileptic activity has been verified or is strongly suspected.

Adenoidectomy↗
PubMed2004

Similar excitation after sevoflurane anaesthesia in young children given rectal morphine or midazolam as premedication.

BACKGROUND: Sevoflurane is a rapid-acting volatile anaesthetic agent frequently used in paediatric anaesthesia despite transient postoperative symptoms of cerebral excitation, particularly in preschool children. This randomised and investigator-blinded study was designed to evaluate whether premedication with an opioid might reduce non-divertible postoperative excitation more than premedication with a benzodiazepine in preschool children anaesthetized with sevoflurane. METHODS: Ninety-two healthy two to six year-old children scheduled for nasal adenoidectomy were randomised to be given rectal atropine 0.02 mg kg(-1) together with either morphine 0.15 mg kg(-1) or midazolam 0.30 mg kg(-1) approximately 30 min before induction and maintenance of sevoflurane anaesthesia. The patient groups were compared pre- and postoperatively by repeated clinical assessments of cerebral excitation according to a modified Objective Pain Discomfort Scale, OPDS. RESULTS: There were no statistically significant postoperative differences in incidence, extent or duration of excitation between children given morphine or midazolam for premedication, whereas morphine was associated with more preoperative excitation than was midazolam. The study groups did not differ significantly with respect to age, weight, duration of surgery and anaesthesia, and time from tracheal extubation to arrival in and discharge from the postoperative ward. CONCLUSION: In this study morphine for premedication in young children anaesthetized with sevoflurane was associated with similar postoperative and higher preoperative OPDS scores compared with midazolam. These findings indicate that substitution of morphine for midazolam is no useful way of reducing clinical excitation after sevoflurane anaesthesia.

Adenoidectomy↗
PubMed2004

Increased rates of ENT surgery among young children: have clinical guidelines made a difference?

OBJECTIVES: To examine the association between introduction of paediatric ear, nose and throat (ENT) surgery guidelines and population procedure rates. To determine changes in children's risk of undergoing ENT surgery. METHODS: Trend analysis of incidence of myringotomy, tonsillectomy and adenoidectomy among New South Wales (NSW) children aged 0-14 between 1981 and mid 1999. Poisson regression models were used to estimate annual rates of change pre and postguidelines introduction and age/gender specific rates, and lifetable methods to determine risk of undergoing an ENT procedure by age 15. RESULTS: ENT surgery rates increased by 21% over the study period. Children's risk of surgery increased from 17.9% in 1981 to 20.2% in 1998/99. Guideline introduction was associated with moderate short-term decreases in rates. For tonsillectomy, rates decreased between 1981 and 1983, but then rose continually until the introduction of myringotomy guidelines in 1993, when they fell, only to recommence rising until the end of the study period. For myringotomy, rates rose annually from 1981 to 1992/93 and fell in the 3 years following guideline introduction, after which they rose again. Increases were almost exclusively restricted to children aged 0-4 and correspond with increased use of formal childcare. The prevalence of myringotomy by the age of 5 years rose from 5.6% of children born in 1988/89 to 6.4% of those born in 1994/95, and the prevalence of tonsillectomy from 2.4% to 2.7%. CONCLUSIONS: The risk of young Australian children undergoing ENT surgery increased significantly over the last two decades despite the introduction of guidelines and no evidence of an increase in otitis media, one condition prompting surgery. Surgery increased most among the very young. We hypothesize this is related to increasing use of childcare.

Adenoidectomy↗
PubMed2005

Unexpected ST segment changes in children--a case report.

In children, myocardial ischemic changes during anesthesia are a rare event unless there is underlying pathology. The patient in this case report was an apparently healthy child scheduled for adenoidectomy and bilateral tympanostomy. Occurrence of significant ST changes as well as intraoperative and postoperative hypoxemia required further diagnostic work-up. Postoperative echocardiographic findings were suspicious of intrapulmonary right to left shunting. The pulmonary arteriovenous fistula is probably the major pathophysiological factor for the development of hypoxemia and paradoxical air embolism especially during positive pressure ventilation in our patient. Unexpected ST segment changes might also occur in patients with anomalous origin of coronary arteries. Although diagnostic work-up was inconclusive, it is necessary to rule out any underlying pathological process. Further follow-up is also important in order to learn more about these disease states that often have subclinical, but potentially fatal presentation.

Adenoidectomy↗
PubMed2005

Children's drawings as a measure of anxiety level: a clinical pilot study.

BACKGROUND: No simple method exists to distinguish children in need for premedication. The present study was planned to detect preoperative anxiety levels of children by rating their drawings. METHODS: Sixty ASA I children aged 4-7 years undergoing adenoidectomy were divided into AGIT and CALM groups according to agitation level observed during venous cannulation. All children drew a picture at three different times: (i) just after arrival in the day-case unit, (ii) 10 min before operation and, (iii) prior to leaving for home. The children were also randomized to three premedication groups: group D, rectal diazepam 0.5 mg x kg(-1); group P, 0.9% NaCl 0.1 ml x kg(-1) rectally; group NT, no premedication. Five features (size of the drawing, form of the drawing line, colors used, mark of the pen and clarity of the picture) from the children's drawings were rated with a 3-point scale. The ratings of each feature were made to form a sum score of anxiety ranging from 0 to 10. In the analysis of variance for repeated measures both the premedication group and agitation score were taken into the model as factors. RESULTS: The anxiety score of the drawings of the agitated children (during venous cannulation) was significantly higher already after arrival in the hospital [AGIT 4.76 (95% CI: 3.56-5.96) Vs CALM 3.67 (95% CI: 2.97-4.37) P = 0.029], but there were no statistical differences between the different premedication groups. CONCLUSIONS: When routine sedative premedication is not used the drawings of the children might detect the children needing sedative premedication.

Adenoidectomy↗
PubMed2006

Acute pancreatitis after anesthesia with propofol in a child with glycogen storage disease type IA.

Glycogen storage disorder type 1A (GSD 1A) is an inherited disorder of glycogen metabolism characterized by fasting hypoglycemia, lactic acidosis, hyperuricemia, and hyperlipidemia. These children have a higher risk of developing pancreatitis because of hypertriglyceridemia. Drug-induced pancreatitis accounts for a small proportion of cases of pancreatitis. The mechanism of drug-induced pancreatitis include hypersensitivity, direct toxic injury or indirectly by inducing hypertriglyceridemia. Propofol is often the drug of choice for induction of anesthesia in ambulatory surgical procedures. There are various reports in the literature describing pancreatitis induced by propofol. We present a 4-year-old girl with GSD 1A, who required tonsillectomy and adenoidectomy under general anesthesia. She developed acute pancreatitis in the postoperative period. Propofol was used as a general anesthetic and the postoperative incidence of pancreatitis is discussed.

Adenoidectomy↗
PubMed1981

Risk factors in multiple sclerosis: tuberculin reactivity, age at measles infection, tonsillectomy and appendectomy.

The purpose of the present study was to investigate whether risk of multiple sclerosis (MS) is associated with the occurrence of viral or bacterial diseases, with vaccinations, or with operative events during childhood. Our reference population was 198,000 persons recorded in the register of school health records from the Copenhagen council. We compared 92 MS patients contained in the register with matched controls from the register, three for each patients. Risk of MS was inversely associated with a positive tuberculin skin test at age 7 years, i.e. with exposure to tuberculosis before the age of 7, possibly also with the occurrence of measles infection before age 7 (not statistically significant). Disease risk was not significantly related to other viral or bacterial infections of childhood, nor to routine vaccinations, tonsillectomy, adenoidectomy or appendectomy. Our findings suggest a difference between MS patients and controls with respect to environment before school age, the former being less exposed to air-borne infections.

Adenoidectomy↗
PubMed1976

Atopic allergy and immunoglobulins in children with adenoids and recurrent otitis media.

From 274 adenoidectomized children 1-16 years of age two groups were selected: children with a history of recurrent otitis media and/or otosalpingitis (middle ear effusion) and those in which nasal obstruction was the main symptom. In all, 154 children were subjected to an allergy investigation including history, skin tests, eye tests, determination of IgE and RAST, blood eosinophils and immunoglobulins G, A and M. No increased incidence of immunoglobulin deficiency was found in either group in comparison with unselected children. A family history of atopic disease and/or otitis media was highly overrepresented, especially in the children with recurrent otitis media as the reason for the adenoidectomy. Atopic diseases had occurred in 24.4% of the children. Furthermore, in both groups there was a high incidence of positive skin and eye tests. An increased incidence of eosinophila, positive RAST tests and elevated IgE levels were also found. In all, 39.6% of the children had two or more laboratory findings characteristic of the atopic state but no significant difference was found between the two groups. Possible connections between atopic allergy and recurrent otitis media are discussed.

Adenoidectomy↗
PubMed1996

B- and T-lymphocyte subpopulations in the adenoids of children with otitis media.

Adenoid hyperplasia is connected with the pathogenesis of otitis media in children, as implicated by the residence of pathogens causing otitis media in adenoids, and by the beneficial effect of adenoidectomy. We have quantitated the proportions of certain T- and B-lymphocyte subsets in the adenoids by three-color flow cytometry. Three groups were studied: 1) children with persistent effusion in the middle ear (pOME), 2) children with recurrent otitis media with no effusion in the middle ear at the time of surgery (rAOM), and 3) children with adenoid hyperplasia without otitis media (AH) presenting either with snoring or upper respiratory tract infections. B lymphocytes comprised on average 64, 66 and 58% of all mononuclear cells in the respective patient groups. The majority of the B lymphocytes were of the follicular mantle zone phenotype expressing surface IgD (on average 69, 67 and 70% of all B lymphocytes in the respective patient groups). Almost one third of the B lymphocytes were of the germinal center cell phenotype, expressing CD38 but negative for surface IgD (on average 29, 30 and 25% in the respective patient groups). CD3+ T lymphocytes comprised 33, 33 and 40%, respectively, of all mononuclear cells, and the average CD4+/CD8+ ratio was 5.2, 4.9 and 5.7, respectively. No statistically significant differences between the patient groups were seen in these T- and B-lymphocyte subpopulations. These results suggest that the relative sizes of the germinal center, follicular mantle and interfollicular compartments of the adenoids do not correlate with the disease status of the middle ear cavity.

Adenoidectomy↗
PubMed2006

How we do it: Transoral suction diathermy adenoid ablation under direct vision using a 45 degree endoscope.

Keypoints * Adenoid ablation using suction diathermy is associated with a number of difficulties, mainly associated with the use of the mirror. Transoral and transnasal 0 degree endoscopes have also been utilised but again have limitations. We describe a technique that overcomes the above problems. * A prospective case series of patients undergoing suction diathermy adenoidectomy under direct vision using a transoral 45 degree endoscope connected to a monitor was conducted, performed by surgical trainees and under direct supervision of the consultant trainer (J.R.-J.). * Intra-operatively, trainees had to demonstrate to the trainer the appropriate anatomy, completed adenoid ablation, and haemostasis. * Fifty-six cases have been performed. In every case, it was possible for the trainer to monitor the trainee's technique throughout the entire procedure. No complications have been reported. * We describe a modified technique which overcomes the disadvantages previously encountered by conventional suction diathermy adenoid ablation.

Adenoidectomy↗
PubMed1993

Penetration of cefprozil into tonsillar and adenoidal tissues.

Penetration of cefprozil into tonsillar and/or adenoidal tissues was investigated for patients undergoing tonsillectomy and/or adenoidectomy. A total of 29 patients ranging in age from 2 to 14 years participated in the study. The tonsils and/or the adenoids were removed at times ranging from 0.33 to 3.17 h after oral administration of a dose of either 7.5 or 20 mg/kg of body weight. A blood sample was also collected as soon as the tissue sample was removed. Plasma, tonsil, and adenoid samples were analyzed for cis and trans isomers of cefprozil by high-performance liquid chromatographic assays. The concentrations of the cis isomer of cefprozil in plasma ranged from 0.60 to 9.87 micrograms/ml at the 7.5-mg/kg dose level and from 1.04 to 20.40 micrograms/ml at the 20-mg/kg dose level. The corresponding concentrations of the cis isomer in tonsil tissue ranged from 0.48 to 2.42 micrograms/g and from 1.00 to 4.29 micrograms/g, respectively. The corresponding concentrations of the cis isomer in adenoid tissue ranged from 0.40 to 4.20 micrograms/g and from 1.74 to 4.94 micrograms/g, respectively. The concentrations of the trans isomer were about 1/10 of those observed for the cis isomer. The median ratios of the cefprozil concentration in tonsillar tissue to that in plasma were 0.37 and 0.47 for patients receiving a 7.5- or a 20-mg/kg oral dose of cefprozil, respectively. The corresponding median ratios for the adenoidal tissue were 0.46 and 0.82, respectively. The cefprozil concentrations in either the tonsillar or the adenoidal tissue at both dose levels over 3.17 h after dosing are much higher than the MICs for common pathogens which cause pharyngitis or tonsillitis.

Adenoidectomy↗
PubMed2004

Structural and immunological characteristics of chronically inflamed adenotonsillar tissue in childhood.

Recurrent or chronic adenotonsillar infections mainly affect children and frequently involve otherwise healthy subjects. Therefore, having excluded systemic immunological deficiencies, this disease may be due to a local dysfunction of the epithelial structures at either the rhino or oropharyngeal level. The aim of the present investigation was to analyze structural and immunological aspects of tonsils and adenoids in subjects who underwent adenotonsillectomy because of recurrent inflammatory episodes with fever. Histological studies and analyses of the cytokine patterns were carried out in palatine tonsils and adenoid samples from 105 patients who underwent adenoidectomy and bilateral extracapsular tonsillectomy for chronic inflammatory hypertrophy of these organs; 46 of the 105 cases examined presented hyperkeratosis of the crypt epithelium; in the remaining 59, the epithelium was hyperplastic with no signs of keratosis. Scanning electron microscopy revealed a continuous epithelial surface of polygon-shaped flattened cells with fissures towards the cryptic depressions. Titration of interleukin-1beta and tumor necrosis factor alpha in serum and tissues demonstrated higher concentrations in the adenotonsillar specimens, whereas the rise in interleukin-6 was more modest.

Adenoidectomy↗
PubMed2005

Adenotonsillectomy for upper respiratory infections: evidence based?

BACKGROUND: Despite high rates of (adeno)tonsillectomy for upper respiratory infections in western countries, the medical literature offers the physician little support in deciding which child might benefit from the operation. METHODS: A literature search was performed to identify randomised trials and non-randomised controlled studies into the efficacy of tonsillectomy with or without adenoidectomy in children under 18 years. For the outcomes sore throat episodes, sore throat associated school absence, and upper respiratory infections, pooled estimates of the incidence rate ratios and rate differences with 95% confidence intervals were calculated, assuming a Poisson distribution. RESULTS: Six randomised trials and seven non-randomised controlled studies on the efficacy of adenotonsillectomy in children were evaluated. For sore throat episodes data for 2483 person-years were available. The pooled risk difference was -1.2 episodes per person-year (95% CI -1.3 to -1.1). For sore throat associated school absence 1669 person-years were analysed. The pooled risk difference was -2.8 days per person-year (95% CI -3.9 to -1.6). For upper respiratory infections 1596 person-years were available. The pooled risk difference was -0.5 episodes per person-year (95% CI -0.7 to -0.3). CONCLUSIONS: All available randomised trials and non-randomised controlled studies into the efficacy of (adeno)tonsillectomy had important limitations. The frequency of sore throat episodes and upper respiratory infections reduces with time whether (adeno)tonsillectomy has been performed or not. (Adeno)tonsillectomy gives an additional, but small, reduction of sore throat episodes, days of sore throat associated school absence, and upper respiratory infections compared to watchful waiting.

Absenteeism↗
PubMed1986

'Near miss' sudden infant death and obstructive apnoea.

A 4 month old girl presented with a 'near miss' sudden infant death episode for which no cause was found. Obstructive sleep apnoea syndrome subsequently developed. All symptoms ceased after adenoidectomy at age 9 months.

Adenoidectomy↗
PubMed1998

Health effects of passive smoking. 4. Parental smoking, middle ear disease and adenotonsillectomy in children.

BACKGROUND: A systematic quantitative review was conducted of evidence relating parental smoking to acute otitis media, recurrent otitis media, middle ear effusion, and adenoidectomy and/or tonsillectomy. METHODS: Forty five relevant publications were identified after consideration of 692 articles selected by electronic search of the Embase and Medline databases using keywords relevant to passive smoking in children. The search was completed in April 1997 and identified 13 studies of acute otitis media, nine of recurrent otitis media, five of middle ear effusion, nine of glue ear surgery, and four of adenotonsillectomy. A quantitative meta-analysis was possible for all outcomes except acute otitis media, using random effects modelling where appropriate to pool odds ratios from each study. RESULTS: Evidence for middle ear disease is remarkably consistent, with pooled odds ratios if either parent smoked of 1.48 (95% CI 1.08 to 2.04) for recurrent otitis media, 1.38 (1.23 to 1.55) for middle ear effusion, and 1.21 (0.95 to 1.53) for outpatient or inpatient referral for glue ear. Odds ratios for acute otitis media are in the range 1.0 to 1.6. No single study simultaneously addresses selection bias, information bias and confounding, but where these have been investigated or excluded in the design or analysis, the associations with parental smoking persist virtually unchanged. Large French and British studies are inconsistent with regard to the association of parental smoking and tonsillectomy. CONCLUSIONS: There is likely to be a causal relationship between parental smoking and both acute and chronic middle ear disease in children.

Acute Disease↗
PubMed1980

Studies on lymphoid cells of adenoid tissue in relation to clinical findings.

Adenoid tissue was obtained at operation in 27 children admitted for adenoidectomy and in 6 controls. The occurrence of cells with cytoplasmic immunoglobulin was studied by immunofluorescence of tissue sections, and localization, number of cells and class of immunoglobulin were determined. No differences were found between patients and controls. Mononuclear leucocytes isolated from adenoid tissue and from blood were compared. In the patients, the proportions of B lymphocytes were higher in the tissue than in the blood, in particular IgG-, IgM- and IgD-carrying cells. Stimulation in vitro with polyclonal activators induced less thymidine incorporation in adenoid cells than in blood cells. Stimulation with heat-killed Haemophilus influenzae induced a high response inadenoid cells from 7/20 patients with negative nasopharyngeal culture for H. influenzae, whereas all 7 patients who harboured H. influenzae in the nasopharynx were low responders.

Adenoidectomy↗